Subsegmental Pulmonary Embolism Research Articles

Pulmonary Embolism in the Cancer Associated Thrombosis Landscape.

In cancer patients, pulmonary embolism (PE) is the second leading cause of death after the cancer itself, most likely because of difficulties in diagnosing the disease due to its nonclassical presentation. The risk of PE recurrence and possibly the case-fatality rate depends on whether the patient presents a symptomatic PE, an unsuspected PE, a subsegmental PE, or a catheter-related PE. Choosing the best therapeutic option is challenging and should consider the risk of both the recurrence of thrombosis and the occurrence of bleeding. The purpose of this review is to provide an overview of the clinical characteristics and the treatment of cancer-associated PE, which could benefit clinicians to better manage the deadliest form of thrombosis associated with cancer. After a brief presentation of the epidemiological data, we will present the current attitude towards the diagnosis and the management of cancer patients with PE. Finally, we will discuss the perspectives of how the medical community can improve the management of this severe medical condition.

Concomitant Deep Vein Thrombosis in Cancer Patients with Unsuspected Pulmonary Embolism.

Simple SummaryCancer patients have a significantly higher risk of developing venous thromboembolism during their disease course when compared with the general population. During routine staging or follow-up imaging studies, incidental venous thromboemboli, including incidental pulmonary embolisms, can be identified. Identifying factors associated with incidental or unsuspected venous thromboembolism is important and can improve the management plan. In the current study, we found that 20.9% of patients with unsuspected pulmonary embolisms had concomitant deep vein thrombosis, and most of these patients were asymptomatic. In addition, we found that concomitant deep vein thrombosis increases the odds of venous thrombosis recurrence in cancer patients presenting with unsuspected pulmonary emboli. Therefore, for patients with isolated incidental subsegmental pulmonary embolism and concomitant deep vein thrombosis, initiating anticoagulants if no contraindications exist is recommended. In addition, the presence of concomitant deep vein thrombosis among cancer patients with unsuspected pulmonary embolisms is associated with poor short- and long-term outcomes in these patients.Incidental venous thromboembolism (VTE) is common in cancer patients and identifying factors associated with these events can improve the management plan. We studied the characteristics of concomitant deep vein thrombosis (C-DVT) in cancer patients presenting with unsuspected pulmonary embolism (PE) and the association of C-DVT with VTE recurrence and survival outcomes. Patients presenting to our emergency department with confirmed unsuspected/incidental PE between 1 January 2006 and 1 January 2016, were identified. Radiologic reports were reviewed to confirm the presence or absence of C-DVT. Logistic regression analyses and cox regression modeling were used to determine the effect of C-DVT on VTE recurrence and survival outcomes. Of 904 eligible patients, 189 (20.9%) had C-DVT. Patients with C-DVT had twice the odds of developing VTE recurrence (odds ratio 2.07, 95% confidence interval 1.21–3.48, p = 0.007). The mortality rates among C-DVT were significantly higher than in patients without. C-DVT was associated with reduced overall survival in patients with unsuspected PE (hazard ratio 1.33, 95% confidence interval 1.09–1.63, p = 0.005). In conclusion, C-DVT in cancer patients who present with unsuspected PE is common and is associated with an increased risk of VTE recurrence and poor short- and long-term survival. Identifying other venous thrombi in cancer patients presenting with unsuspected PE is recommended and can guide the management plan. For patients with isolated incidental subsegmental pulmonary embolism and concomitant deep vein thrombosis, initiating anticoagulants if no contraindications exist is recommended.

Subsegmental pulmonary embolism and anticoagulant therapy: the impact of clinical context.

Anticoagulation for subsegmental pulmonary embolism (SSPE) is controversial. To assess the impact of clinical context on anticoagulation and outcomes of SSPE. We electronically searched computed tomography pulmonary angiogram reports to identify SSPE. We extracted demographic, risk factor, investigations and outcome data from the electronic medical record. We stratified patients according to anticoagulation and no anticoagulation. From 1 January 2017 to 31 December 2019, we identified 166 patients with SSPE in 5827 pulmonary angiogram reports. Of these, 123 (74%) received anticoagulation. Compared with non-anticoagulated patients, such patients had a different clinical context: higher rates of previous venous thromboembolism (11% vs 0%; P = 0.019), more recent surgery (26% vs 9%; P = 0.015), more elevated serum D-dimer (22% vs 5%; P = 0.004), more lung parenchymal abnormalities (76% vs 61%; P = 0.037) and were almost twice as likely to require inpatient care (76% vs 42%; P < 0.001). Such patients also had twice the all-cause mortality at 1 year (32% vs 16%). SSPE is diagnosed in almost 3% of pulmonary angiograms and is associated with high mortality, regardless of anticoagulation, due to coexistent disease processes rather than SSPE. Anticoagulation appears dominant but markedly affected by the clinical context of risk factors, alternative indications and illness severity. Thus, the controversy is partly artificial because anticoagulation after SSPE is clinically contextual with SSPE as only one of several factors.

The prevalence of pulmonary embolism among COVID-19 patients underwent CT pulmonary angiography

BackgroundPulmonary embolism (PE) is a common and fatal complication of COVID-19 infection. COVID-19's main clinical manifestations are not only pneumonia but also coagulation disorders. This study evaluates the prevalence of pulmonary embolism at CT pulmonary angiography (CTA) for positive coronavirus patients as well as the factors associated with PE severity. Materials and methodsThis is a retrospective cross-sectional study that was conducted at King Faisal Medical Complex (KFMC) in Taif city of Saudi Arabia from June 2020 to June 2021. Data was collected from the picture archiving and communication system (PACs) for a total of 445 positive patients who underwent CT pulmonary angiography and analyzed using SPSS. ResultsThe mean age and gender of the male were 57.3 ± 15.8 years and 64.5%, respectively. The prevalence of pulmonary embolism at CTA among patients with COVID-19 was found to be 8.1%. Bilateral segmental and bilateral subsegmental pulmonary embolism were found to be the most common sites for PE (16.7% for each). Furthermore, shortness of breath (SOB) was found to be the most common reported symptom among the respondents. Lastly, shortness of breath, chest pain, loss of taste or smell, D-dimer, and cardiac troponin were found to be significantly associated with PE (P-value = < 0.001, <0.001, 0.001, <0.001 and 0.037 respectively). ConclusionPresent results show that the prevalence of pulmonary embolism among COVID19 patients with CT Pulmonary Angiography at KFMC is relatively low (8.1%) and most of the patients were from the ICU department. Early detection and treatment of COVID-19 patients with PE and APE complications are critical for lowering the mortality rate.

Platelet transfusion and anticoagulation in hematological cancer‐associated thrombosis and thrombocytopenia: The CAVEaT multicenter prospective cohort

BackgroundVenous thromboembolism (VTE) in patients with thrombocytopenia represents a complex management challenge. ObjectivesTo describe practice, document outcomes, and compare management to national guidelines. MethodsWe present a prospective multicenter cohort of 105 patients with hematological cancer, VTE within 28 days, and platelets <50 × 109/L from May 14, 2019 to April 24, 2021 from 20 sites. ResultsMedian age was 64 and median initial platelet count 28 × 109/L. Thromboses were: 46% catheter‐associated, 11% lower limb, 33% pulmonary emboli (PE), and 10% other sites. Management was according to International Society on Thrombosis and Haemostasis (ISTH) guidance in 30 (47%) of 64 patients with high‐risk thrombosis and 2 (5%) of low‐risk thrombosis (catheter‐associated or asymptomatic subsegmental PE). Twelve patients (11%) received no anticoagulation. At 28 days mortality was 15%, 8% experienced VTE progression, 7% experienced major bleeding, and 25% experienced clinically relevant non‐major bleeding. Four inferior vena cava filters were placed, two were later removed. The median number of platelet units transfused was 5 (range 0–53). Twenty‐seven percent of patients had a change of management strategy by 28 days. There was no clear relationship among platelet transfusion threshold, anticoagulant dose reduction threshold, and risk of thrombosis progression or major bleeding. ConclusionsThis data set demonstrates the heterogeneity of approaches used in patients presenting with severe thrombocytopenia and acute thrombosis and confirms the high rates of bleeding in this cohort with thrombosis progression rates similar to the wider cancer‐associated thrombosis population. Randomized data is required to inform the optimal management.

What to do about subsegmental pulmonary embolism?

What to do about subsegmental pulmonary embolism?

P1675: POST-HOSPITAL DISCHARGE EVALUATION OF COVID-19 SURVIVORS WHO SUFFERED ACUTE VENOUS THROMBOEMBOLISM (VTE) DURING HOSPITALIZATION: THE BERGAMO EXPERIENCE

Background: Acute COVID-19 manifestations are well known, while post-COVID clinical and laboratory consequences are less clear. Due to the strict association of COVID-19 with thrombosis, the Hemostasis Service of Bergamo hospital had a central role in guiding anticoagulant treatments in patients during the acute and post-discharge phases. Aims: In the post-hospital discharge setting, in a cohort of COVID-19 survivors who experienced VTE during the acute phase and were followed up at our outpatient clinic, we aim to evaluate whether alterations in coagulation and inflammatory parameters were occurring and were possibly associated with disease severity. Methods: An outpatient service specifically dedicated to follow-up of COVID-19 survivors was set up at our Institution. A retrospective analysis of a cohort of 1563 patients enrolled from May 2020 to November 2020 was performed. Data were obtained on the occurrence or not of acute COVID-19 -associated VTE, the site of thrombosis, ongoing anticoagulant treatments, and the results of laboratory tests performed at the first post-discharge assessment visit, including blood cell count, D-dimer, fibrinogen, CRP and LDH. The severity degree of COVID-19 at the onset was defined by the need of Continuous Positive Airway Pressure devices (C-PAP) or tracheal intubation as compared to no-oxygen need, or use of nasal flow, reservoir mask, or Venturi Mask. Statistical analyses were performed using SPSS v21 software. Results of lab tests were expressed as median values (5th-95th percentile). Results: Of the 1563 enrolled outpatient COVID-19 survivors [974 M/589 F, median age of 60 years (35.5-81)], 56 subjects [43M/13F; median age 62 years (42-80.5)] had had VTE during COVID-19 acute phase (3.58%), as follows: 9 isolated proximal DVT (4 in upper extremity), 45 isolated PE (34 subsegmental and/or segmental PE; 11 central pulmonary artery thrombosis), 2 DVT+PE. Concerning COVID-19 severity, 33 of 56 patients needed C-PAP or tracheal intubation. At the follow-up visit, patients were still on anticoagulation (76% with DOAC). Laboratory data analyses revealed that 25% of VTE-subjects had increased levels of both D-dimer and fibrinogen, and 11% had elevated levels of CRP, while no abnormalities were observed in the platelet and leucocyte counts. CRP significantly correlated with fibrinogen and D-Dimer levels. According to COVID-19 severity, only platelet count was significantly higher in patients with severe disease, who needed C-PAP or tracheal intubation, as compared to those with less severe disease. No patients had VTE recurrence or bleeding complications at the time of follow up. Summary/Conclusion: Our data suggest persistence of pro-coagulant and inflammatory laboratory patterns in a proportion of patients with COVID-19-related VTE, in spite of anticoagulant therapy. Further studies are needed to establish on whether monitoring these parameters may help in the decision on the duration of anticoagulation in this condition.

P87 MEDIASTINAL SYNDROME REVEALED HEART LOCALIZATION OF A PRIMARY MEDIASTINAL B–CELL LYMPHOMA

Abstract Background Primary mediastinal B–cell lymphoma (PMBCL) is an aggressive B–cell lymphoma that represents 2–3% of non –Hodgkin lymphoma cases and typically affects young adult Caucasian women. Diagnosis can be difficult and often need a multidisciplinary approach. Case a 75 year old female, with history of hypertension, came to ER for severe dyspnea. She complains also neck and left arm oedema. Blue swelling of face and trunk were described. Heart PoCUS was inconclusive, describing only a hypoechoic dilation of right atrium while the other three heart chambers were reduced in dimensions. Chest TC revealed a huge mediastinal mass next to a thrombosis of superior cava vein and right atrium (7 cm diameter) and a diffuse subsegmental pulmonary embolism. Arm and neck Lymphnodes were also enlarged . Low molecular weight heparin was given twice a day. Due the respiratory failure a high–flow nasal cannula oxygen treatment was performed. PET revealed FDG uptake in antero–superior mediastinum, but there was the same uptake in heart right atrium without a connection with the previous described. Therefore, this was no more considered as thrombus but as mass. The micro–bubble test revealed right to left shunt. She refused heart MRI. The patient was not suitable for an open–surgery biopsy, thus she was scheduled for a TC guided one, in order to obtain a pathological diagnosis for a suspected right atrium sarcoma. Due to the high risk we choose to perform the less invasive as possible way to have a histological sample. Thus, and intravascular biopsy of atrial mass by femoral vein was performed. The patient did not present any sequelae after procedure and she continued anticoagulation. The subsequent histological analysis revealed a PMBCL with a primary localization in Right atrium. Unfortunately, a sepsis by multiple resistant pseudomonas Aeruginosa and Aspergillus spp. arose and the patient died three weeks after biopsy. Conclusion A PMBCL is a rare and aggressive disease. Like in our patient, mediastinal syndrome is often associated to the disease. However, intracardiac localization are even rarer events. In large case series, less than 1% of intracardiac masses were lymphomas. In our patient, open–surgery was not suitable for multiple comorbidities. However, intravascular approach was less aggressive but effective to obtain enough tissue for diagnosis. Unfortunately, the immune suppression related to PMBCL and opportunistic infections drive a mortal sepsis.

A survey of physicians’ opinions about the treatment of subsegmental pulmonary embolism

IntroductionThe aim of this study was to survey the attitudes of internists, cardiologists, and pulmonologists regarding treatment or no treatment of isolated subsegmental pulmonary embolism (ISSPE) with anticoagulant drugs.MethodsQualified physicians were asked to select their management options from a questionnaire that included a patient scenario with subsegmental pulmonary embolism (SSPE) and negative past medical history of thromboembolism.ResultsA total of 113 physicians responded to the survey. Of these, 8.8% preferred not to treat patients without further evaluation; 15% decided not to treat, but follow-up the patient with a serial lower-limb colour Doppler ultrasonography; 1.7% preferred anticoagulant treatment only during hospitalization and follow-up without medication; 5% preferred anticoagulant treatment for less than 3 months; and 34.5% chose a 3–6-month treatment with anticoagulation. Furthermore, 24% of physicians opted for anticoagulant treatment for more than 6 months, and 9.7% left the decision up to the patient. Opting not to treat was an option selected by more board-certified faculty members specialized in cardiology, internal medicine, and pulmonology compared with residents (p = 0.038). Willingness to provide anticoagulant therapy in the internal medicine, cardiology and pulmonology groups was 56.6%, 37.3% and 6%, respectively (p = 0.007).ConclusionThe majority of physicians surveyed prefer anticoagulant therapy in patients with SSPE.

Early Detection and Management of Venous Thrombosis in Skull Base Surgery: Role of Routine Doppler Ultrasound Monitoring.

Venous thromboembolism (VTE), encompassing deep venous thrombosis (DVT) and pulmonary embolism (PE), causes postoperative morbidity and mortality in neurosurgical patients. The use of pharmacological prophylaxis for DVT prevention in the immediate postoperative period carries increased risk of intracranial hemorrhage, especially after skull base surgeries. To investigate the impact of routine Doppler ultrasound monitoring in prevention and tiered management of VTE after skull base surgery. We retrospectively analyzed a large cohort of consecutive adult patients who were prospectively and uniformly managed with routine monitoring by Doppler ultrasound for DVT after resection of a skull base tumor. A total of 389 patients who underwent 459 surgeries for intracranial tumor resection were analyzed. Skull base meningioma was the most common pathology. Forty-four (9.59%) postoperative VTEs were detected: 9 (1.96%) with PE with or without DVT and 35 (7.63%) with DVT alone. Four cases of subsegmental PE were diagnosed without evidence of lower extremity DVT, possibly in the setting of peripherally inserted central catheters maintenance. One patient had a preoperative proximal DVT and underwent a prophylactic inferior vena cava filter but expired from PE after discharge. Prior history of VTE (risk ratio [RR] 5.13; 95% CI 2.76-7.18; P < .01), anesthesia duration (RR 1.14; 95% CI 1.03-1.27; P = .02), and blood transfusion (RR 1.95; 95% CI 1.01-3.37; P = .04) were associated with VTE development on multivariate analysis. Routine postoperative venous ultrasound monitoring detects asymptomatic DVT guiding management. This is an alternative strategy to prescribing pharmacological VTE prophylaxis immediately after lengthy surgeries for intracranial tumors. Peripherally inserted central catheters were associated with subsegmental PE.

PoCUS: Just because we can doesn't mean we should.

PoCUS: Just because we can doesn't mean we should.

Overdiagnosis in the emergency department: a sharper focus

Overdiagnosis occurs when a person's symptoms or life experiences are given a diagnostic label that ultimately causes them more harm than good. We describe the complex drivers of overdiagnosis spanning five interconnected domains, which can lead to numerous negative impacts on patients. Emergency physicians are often tasked with making timely clinical assessments, decisions, and diagnoses that can unintentionally result in overdiagnosis. Three pertinent areas related to overdiagnosis in Emergency Medicine: anaphylaxis, subsegmental pulmonary embolism, and low-risk chest pain are discussed. For a broader perspective, insight on overdiagnosis from medical students and a patient advisor are presented. The perspectives illustrated are meant to spark reflection on: the ethics of labeling a person with a diagnosis, current clinical practices, the limitations of medical education, and patient care and communication in the context of overdiagnosis in the Emergency Department.

Translated article] Multidisciplinary consensus for the management of pulmonary thromboembolism

We have updated recommendations on 12 controversial topics that were published in the 2013 National Consensus on the diagnosis, risk stratification and treatment of patients with pulmonary embolism (PE). A comprehensive review of the literature was performed for each topic, and each recommendation was evaluated in two teleconferences. For diagnosis, we recommend against using the Pulmonary Embolism Rule Out Criteria (PERC) rule as the only test to rule out PE, and we recommend using a d-dimer cutoff adjusted to age to rule out PE. We suggest using computed tomography pulmonary angiogram as the imaging test of choice for the majority of patients with suspected PE. We recommend using direct oral anticoagulants (over vitamin K antagonists) for the vast majority of patients with acute PE, and we suggest using anticoagulation for patients with isolated subsegmental PE. We recommend against inserting an inferior cava filter for the majority of patients with PE, and we recommend using full-dose systemic thrombolytic therapy for PE patients requiring reperfusion. The decision to stop anticoagulants at 3 months or to treat indefinitely mainly depends on the presence (or absence) and type of risk factor for venous thromboembolism, and we recommend against thrombophilia testing to decide duration of anticoagulation. Finally, we suggest against extensive screening for occult cancer in patients with PE.

HIV Infection Diagnosis in a Late Presenter Patient during a Severe Imported Falciparum Malaria: A Challenging

BACKGROUND: Malaria and HIV share the same epidemiological spreading and coinfection may be clinically challenging. In 2019, nearly all malaria cases reported by EU/EEA countries were imported. Severe falciparum malaria is a medical emergency often associated with poor outcome, even when treated with appropriate therapy. CASE PRESENTATION: Here, we described an unusual case of a late presenter HIV diagnosis made during the management of a severe falciparum malaria in an Italian traveler returning from Nigeria, who did not take antimalaria prophylaxis. Clinical course was complicated by the occurrence of several superinfections caused by deep immunosuppression, and bilateral subsegmental pulmonary embolism. CONCLUSION: Although critical conditions, malaria prompt diagnosis and treatment, along with HIV diagnosis and the successful treatment of occurred superinfection, resulted in a positive outcome.

Negative Venous Leg Ultrasound in Acute Pulmonary Embolism: Prevalence, Clinical Characteristics and Predictors.

The purpose of this study was to investigate the prevalence, clinical characteristics, and predictors of negative venous leg ultrasound in acute pulmonary embolism (PE). We retrospectively analyzed a cohort of 168 patients with acute PE (median age 73 years, 44% women) evaluated with complete venous leg ultrasound. A multivariate logistic regression analysis was performed to identify the independent predictors of negative venous ultrasound in acute PE. Venous leg ultrasound was negative for deep venous thrombosis (DVT) in 78 patients (46.4%). Patients with negative venous ultrasound were less likely to have a history of DVT (7.7% vs. 20.0%, p = 0.0273) and had significantly lower D-dimer levels (median 2.5 vs. 6.2 mg/dL p < 0.0001). Negative venous ultrasound was more frequent in PE diagnosed with V/P-SPECT than in PE diagnosed with CT (66.2% vs. 34.0%, p < 0.0001). The prevalence of negative venous ultrasound increased with more peripherally located PE (29.5% for central/lobar, 43.1% for segmental, and 60.6% for subsegmental PE, p = 0.0049). For the multivariate analysis, a diagnosis of PE with V/P-SPECT rather than CT (OR 3.2, p = 0.0056) and lower D-dimer levels (OR 0.94, p = 0.0266) were independent predictors of negative venous ultrasound. In conclusion, venous leg ultrasound was negative for DVT in almost half of patients with acute PE. Negative venous ultrasound was more common in patients with no history of DVT, lower D-dimer levels, PE diagnosed with V/P-SPECT rather than CT, and more peripherally located PE.

Influence of using recommended radiological criteria on MDCT-angiography diagnosis of single isolated subsegmental pulmonary embolism

We assessed the rate of false-positive diagnoses of MDCT-pulmonary angiography (MDCT-A) in patients with single isolated subsegmental pulmonary embolism (SISSPE). All patients who underwent MDCT-A between 2006 and 2017 for ruling out acute pulmonary embolism (PE) and received an initial diagnosis of SISSPE were included. The MDCT-A of these patients were reviewed retrospectively by four experienced thoracic radiologists, who applied radiological criteria recommended by the American College of Chest Physicians Antithrombotic Guidelines (ACCP 2016) for the diagnosis of SISSPE. Data extracted from medical records were history of venous thromboembolism (VTE), alternative diagnoses, other diagnostic studies for VTE, anticoagulation, bleeding complications, and VTE over the following 3months. Of 3839 patients undergoing MDCT-A, PE was found in 1021 (26.6%) and SISSPE in 59 (1.5% overall and 5.8% of all patients with PE). An alternative diagnosis to PE was made on the basis of CT in 33 (55.9%) patients. Forty-one (69.5%) patients received anticoagulants, and major life-threatening bleeding complications occurred in 2, with one death. Recurrent PE was not documented in any patient with SISSPE. In the retrospective assessment of the 59 cases of SISSPE, 21 were negative for PE, with a false-positive rate of 35.6% (21/59); so the percentage of SISSPE cases after the revision was 3.7% of all patients with PE; 11 of these 21 patients received anticoagulation. Radiologists should be aware of the high rate of false-positives when making the diagnosis of SISSPE on MDCT-A without using strict diagnostic criteria. Misdiagnosis exposes patients to unnecessary anticoagulation. • Radiologist should be aware of the high rate of false-positive diagnoses of single isolated subsegmental pulmonary embolism (SISSPE) in MDCT-pulmonary angiography (MDCT-A) performed for ruling out pulmonary embolism. • Misdiagnosis of SISSPE in MDCT-A can be reduced by using strict diagnostic radiological criteria recommended by the American College of Chest Physicians Antithrombotic Guidelines. • Unnecessary anticoagulation therapy with potential severe bleeding complications may result from misdiagnosis of SISSPE.

Dual-energy ct angiography for detection of pulmonary emboli: incremental benefit of iodine maps

Purpose: To determine if there is an added benefit of using iodine maps from dual-energy (DECT) in addition to conventional CT angiography images to diagnose pulmonary embolism (PE).Materials and Methods: In this retrospective analysis, 49 consecutive dual-energy CT angiography examinations performed from August through July 2020 at Bach Mai Hospital to evaluate for PE were reviewed. The 49 examinations included 49 patients (mean age, 59.73 years; range, 22–99 years). First, the location, level, and type (occlusive vs nonocclusive) of PEs on conventional CT angiograms were recorded. Iodine maps were then reviewed for defects suggestive of PE. Last, CT angiograms were rereviewed to detect additional PEs suggested by the iodine map.Results: 19/49 (38.8%) patients were diagnosed with PE, a total of 247 PEs were detected at initial review. After review of the DECT iodine map, 16 additional PEs were found on 8 of 49 (16.3%) patients in which 2 of 49 (4 %) patients had a new diagnosis of PE after review of the DECT iodine maps, 4/49 (8%) patients were diagnosed PE before. Of the 16 additional PEs, 8 (50%) were segmental, 8 (50%) were subsegmental, 3 (18.8 %) were occlusive, and 13 (81.2%) were nonocclusiveConclusion: Dual-energy CT iodine maps show a small incremental benefit for the detection of occlusive segmental and subsegmental pulmonary emboli.

Single versus multiple and incidental versus symptomatic subsegmental pulmonary embolism: clinical characteristics and outcome.

It remains unexplored if the clinical picture and outcome of subsegmental pulmonary embolism (SSPE) differ between single versus multiple, and incidental versus symptomatic embolism. Consecutive patients anticoagulated for SSPE at the Mayo Thrombophilia Clinic (03/01/2013-12/31/2020) were followed forward to assess venous thromboembolism (VTE) recurrence, mortality, major bleeding, and clinically relevant non-major bleeding (CRNMB); expressed as a rate per 100 person-years. Among 3878 VTE patients, 1541 had pulmonary embolism including 224 (14.6%) with SSPE either single (n = 139) or multiple (n = 85; 46 bilateral and 39 unilateral emboli); 134 had incidental and 90 symptomatic SSPE. Patients with single were less often symptomatic and less often had coexisting DVT than multiple SSPE. Patients with incidental had a two-fold higher frequency of cancer compared to symptomatic SSPE. During the study period, 1 patient with single and 2 with multiple SSPE had VTE recurrence (rate of 1.14 vs 3.63, p = 0.280). Single SSPE patients experienced 2 episodes of major bleeding (rate of 2.36) while the multiple SSPE group had no major bleeding. Seven patients in each group had CRNMB events (rate of 8.20 vs 13.58 for single and multiple SSPE, respectively, p = 0.282). Patients with single SSPE had a higher death rate compared to multiple SSPE (43.07 vs 22.22, p = 0.031) but no difference was noted after adjusting for cancer (p = 0.388). Also, incidental had similar clinical outcomes to symptomatic SSPE.Interpretation Anticoagulated SSPE patients with single and multiple as well as incidental and symptomatic have a different clinical profile but similar clinical outcomes.

Comparison of high-pitch prospective electrocardiogram-gated pulmonary CT angiography with standard CT pulmonary angiography on dual-source CT for detection of subsegmental pulmonary embolism in patients suspected of acute pulmonary embolism.

PurposeObjective of this study was to compare high-pitch prospective electrocardiogram (ECG)-gated computed tomography (CT) pulmonary angiography (HP-PECG-gated CTPA) with standard-pitch non-ECG-gated CT pulmonary angiography (SP-NECG-gated CTPA) on 128-slice dual-source CT (DSCT) for the detection of subsegmental pulmonary embolism (SSPE) in patients suspected of acute pulmonary embolism (APE) with radiation and contrastoptimized protocols. Cardiac-related motion artefacts, lung image quality, and quantitative parameter (pulmonary arterial enhancement, radiation exposure, and contrast) volumes were also compared.Material and methodsThis prospective study enrolled 87 patients clinically suspected of APE and randomly distributed to either group by software. Two radiologists blinded to each other interpreted the images for assessment of SSPE, image quality, and quantitative parameters.ResultsSSPE was diagnosed in 15/44 (34.09%) patients in HP-PECG-gated CTPA, in comparison to 8/43 (18.60%) patients in SP-NECG-gated CTPA. Cardiac motion-related artefacts (blurring of bronchovascular structures and double-line artefacts) were statistically significantly less, with p-value < 0.05. Lung image quality was also better, with p-value < 0.001. Effective radiation dose and contrast volume in HP-PECG-gated CTPA were (2.54 ± 0.80 mSv, 45.05 ± 6 ml) versus SP-NECG-gated CTPA (3.17 ± 1.20 mSv, 74.19 ± 7.63 ml) with p-values of 0.007 and 0.001, respectively.ConclusionsRadiation and contrast volume-optimized HP-PECG-gated CTPA provides reduced cardiac motion related artefacts of pulmonary arteries, which allows enhanced detection of SSPE. It also provides better image quality of lung and parenchyma with lower radiation exposure and less contrast volume

Annals for Educators - January 2022.

Annals for Educators - January 2022.